MEDICARE: AMY LUITJOHAN STOFFREGEN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	7196	OH

General Provider Information

NPI Number	:	1336549773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LUITJOHAN STOFFREGEN PSYD

Provider Business Mailing Address
First Line	:	1520 OLD HENDERSON RD STE 100D
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-3639
Country	:	US
Telephone Number	:	614-547-7868
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 OLD HENDERSON RD STE 100D
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-3639
Country	:	US
Telephone Number	:	614-456-7777
Fax Number	:	614-547-7868

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	07/08/2020

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